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What is a "pitfall nose", and how does it impact your surgery?

One of the reasons why rhinoplasty is so difficult is that the anatomy of the nose varies dramatically from patient to patient. Many patients wonder why their nose required more grafting or why their healing took longer. These differences from patient to patient are based on anatomy. Some patients have variant nasal anatomy that set them up for problems such as collapse and deformity. I have a term I use for this group of patients who are a set-up for a poor outcome. I refer to such noses as "pitfall noses". Their anatomy sets them up for deformity, collapse and functional problems after surgery.

Patient with "pitfall noses" tend to have what is called "cephalic positioning of the lateral crura", which is a variant orientation of the lower lateral or nasal tip cartilages. This is a very common variant form of anatomy, and patients can have varying degrees of deformity. The nasal tip is bulbous and looks like a "parentheses" on frontal view (see the patient below). This patient has a very bulbous nasal tip and a narrow, weak middle nasal vault cartilage (upper lateral cartilage). These patients tend to have problems with nasal obstruction prior to surgery. They frequently have collapse of the nostrils when they breathe in (See preop base view without and with inspiration). Note how the nostrils collapse with inhalation. If this collapse is not corrected, then the patient will likely have severe nasal obstruction after surgery. Special grafting techniques are required to correct these deformities. Some patients with "pitfall noses" may not have adequate grafting material in the septum and may need to have costal (rib) cartilage harvested for the grafting material.

 Illustrative patient cases:


<click on images to enlarge>







Treatment of this patient required cartilage grafting to stabilize the nose and make sure that her nose does not collapse over time. She underwent spreader grafting and lateral crural strut grafting to stabilize the weak structures of her nose. Her lower lateral cartilages were repositioned into a more normal position to improve tip shape and correct her breathing problems. Fortunately, she had plenty of her own septal cartilage for the cartilage grafting procedures, so additional cartilage, such as from the rib, was not needed. She also underwent placement of spreader grafts to widen her middle third of her nose so it does not collapse over time. Failure to treat the middle vault would leave her with a narrower nose early on that would likely collapse latter on. With the grafting, her nose will continue to improve over time, and her breathing should be good as well.




Postoperatively, she has done well, and she has a good aesthetic and functional outcome over one year after surgery (see photos of postoperative results). Her nasal breathing is much improved, and her nose is very stable and should not collapse over time.






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